Method of detecting cancer

ABSTRACT

The disclosure provides methods for resolving an inconclusive cytological assessment of clinically relevant cells in a sample obtained from a patient based on the cytological detection of antibody binding to telomerase in clinically relevant cells in the sample, wherein binding of the antibody to clinically relevant cells indicates the presence of malignant or cancerous cells.

TECHNICAL FIELD

The present disclosure relates to methods of determining whether asubject has cancer. More particularly, the present disclosure relates toa method of determining whether a subject has cancer when a cytologicalassessment of cell morphology is inconclusive for the cancer.

BACKGROUND OF THE INVENTION

The development and progression of cancer places a significant emotionaland financial burden on society.

Bladder cancer is the second most common genitourinary tumour in humanpopulations, with an incidence of approximately 261,000 new cases eachyear worldwide; about a third of those are likely to be invasive ormetastatic disease at the time of diagnosis (Parkin et al., 1999).

As with many other cancers, clinical diagnosis of bladder cancer can bea difficult process, particularly in the early stages of cancerdevelopment. At present, cystoscopy and urine cytology are the mostimportant tools in the diagnosis and follow-up of bladder cancer.

At present, cystoscopy with biopsy is generally considered the goldstandard for diagnosing bladder cancer. A drawback to using cystoscopyis that it requires an invasive procedure. In addition to beinginvasive, obtaining a biopsy via cystoscopy can have potential adverseoutcomes for the patient. Given these limitations, it is very difficultto obtain patient samples via cystoscopy, repeatedly from a large numberof individuals.

Accordingly, clinicians generally rely on routine cytology to identifypatients at risk of developing bladder cancer prior to cystoscopy.Routine cytology suffers from two well accepted limitations that reduceits utility as a diagnostic tool for early stage cancer.

First, cytology has poor sensitivity for low grade cancer. Accordingly,routine cytology returns a high level of false-negative results inlow-grade cancer samples that completely lack cellular morphologicalabnormalities. Second, the usefulness of cytology for the detection oflow grade disease, or hard to diagnose lesions, is limited. For example,when using cytology for the diagnosis of bladder cancer, a largeproportion of cases (20-25%) are reported as atypical, including“atypical urothelial cells of unknown significance” (AUCUS) and“atypical urothelial cells, cannot exclude high-grade urothelialcarcinoma (AUHGC)” (Rosenthal et al., 2013). A reported outcome of AUCUSor AUHGC is of little or no diagnostic utility.

A need therefore exists for a method capable of providing a moreaccurate, early and economically viable diagnosis of cancers. Such amethod could provide assistance to clinicians in reaching an early stagediagnosis prior to the portrayal of detectable morphological indicators.Moreover, early diagnosis of cancer, prior to invasion and metastasis,is generally associated with improved prognosis. Accordingly, there is asocial and economic imperative to provide a method that can morereliably detect cancer at an early stage, so anti-cancer therapy can beadministered at a time when the disease burden is mild.

SUMMARY OF THE INVENTION

The present disclosure can be used to assist in resolving aninconclusive cytological assessment of cancer, and hence may be used asa reflexive test to inconclusive cytological assessment procedures.Thus, in a first aspect, the present disclosure provides a method ofresolving an inconclusive cytological assessment of clinically relevantcells in a sample obtained from a patient, the method comprisingcontacting cells from the sample with an anti-telomerase antibody andperforming a cytological assessment of the cells to detect binding ofthe antibody to clinically relevant cells, wherein binding of theantibody to clinically relevant cells indicates the presence ofmalignant cells.

The method of the present disclosure may be used to resolve aninconclusive cytological assessment of clinically relevant cells in asample obtained from a patient.

For example, the methods of the present disclosure may comprisecontacting a patient sample comprising clinically relevant cells ofinconclusive cytology with an anti-telomerase antibody and detecting thepresence or absence of binding of the antibody to the clinicallyrelevant cells of inconclusive cytology, wherein binding of the antibodyto clinically relevant cells of inconclusive cytology indicates thepresence of malignant cells.

In an embodiment of the above aspect, the absence of antibody binding toclinically relevant cells indicates that malignant cells are not presentin the sample.

In a further aspect, the present disclosure relates to a method ofdetermining whether a subject has cancer when a cytological assessmentof cell morphology is inconclusive for the cancer, the methodcomprising:

i) contacting a cell sample from the subject with an anti-telomeraseantibody;

ii) performing a cytological assessment of the cell sample to detectbinding of the antibody to clinically relevant cells in the sample;

wherein binding of the antibody to one or more clinically relevant cellsin the sample indicates that the subject has cancer.

When cancer is determined using a method of the disclosure thedetermination may or may not be conclusive with respect to thedefinitive diagnosis upon which a treating physician will determine acourse of treatment. The definitive diagnosis of the cancer status of asubject determined to have cancer can be validated or confirmed ifwarranted, such as through imaging techniques including, PET, MRI,ultrasound, CT, PET/CT. In an embodiment of the above aspects, when thecancer being determined is bladder cancer, further investigation viacystoscopy with biopsy or upper tract imaging may be used to obtain adefinitive diagnosis of the cancer status.

The present disclosure can also be used as a frontline, adjunctive test,to more accurately determine the presence of malignant cells in a singleprocedure. Accordingly, in a further aspect, the present disclosureprovides a method of determining whether a subject has cancer, themethod comprising:

i) performing a cytological assessment of cell morphology on a cellsample from the subject to determine the morphology of one or moreclinically relevant cells in the sample;

ii) contacting a cell sample from the subject with an anti-telomeraseantibody and performing a cytological assessment of the cell sample todetect binding of the antibody to clinically relevant cells in thesample;

wherein when the cytological assessment of cell morphology isinconclusive for the cancer, binding of the antibody to one or moreclinically relevant cells indicates that the subject has cancer.

In an embodiment of the above aspects, binding of the antibody to atleast about 5% of clinically relevant cells in the sample indicates thatthe subject has cancer.

Further, the cytological morphological assessment and detection oftelomerase can be performed in any order or simultaneously on the samecells.

In an embodiment, binding of an anti-telomerase antibody to cells withan atypical cytology indicates that the subject has cancer. For example,the methods of the present disclosure identifies the subject as having amalignant cancer when binding of the antibody to cells with an atypicalor indeterminate cytology is detected.

In an embodiment, the absence of anti-telomerase antibody binding toclinically relevant cells indicates that the cells in the sample are notmalignant. For example, the methods of the present disclosure identifiesthe subject does not have malignant cancer cells when antibody bindingto clinically relevant cells is not detected.

In another embodiment, the methods of the present disclosure comprisesdirecting treatment of the subject for a malignant cancer when bindingof the antibody to cells with an atypical or indeterminate cytology isdetected.

As will be appreciated by one of skill in the art, cytologicalassessment involves the assessment of individual cells. Accordingly, inperforming the present method the individual cells are cytologicallyassessed to detect binding of an anti-telomerase antibody to clinicallyrelevant cells. Cytological assessment of telomerase allows telomerasestained cell types which are known to be non-cancerous to be excludedfrom the assessment based on their morphology. For example, the methodsof the present disclosure comprise excluding non-clinically relevantcells from the cytological assessment.

Excluded cells are considered not clinically relevant to determiningwhether a subject has cancer. The excluded cells will depend on thecancer being detected. More specifically, the skilled person will beaware of cell types in a sample related to a particular cancer. Examplesof excluded cells include, but are not necessarily limited to, one ormore or all of T-cells, B-cells, neutrophils, macrophages, granulocytes,dendritic cells, mast cells, memory-cells, plasma cells, eosinophils,renal tubular cells, seminal vesicle cells, sperm, and squamous cells.For example, the cells listed above will be excluded when assessingbladder cancer using the methods of the disclosure.

The sample can be any suitable type known to potentially includemalignant cells. Examples of suitable samples include, but are notnecessarily limited to, biopsy material, resection material, urine,bladder washings, bladder scrubbings, blood, sputum, cerebrospinalfluid, pleural effusions, abdominal ascites, liver, thyroid, ovary,lymph node, breast, cervix, lung, biliary tree, pancreas, lung andcolon. In an embodiment, the sample is a fluid sample.

In an embodiment, the cancer is bladder cancer and the sample is urine,bladder washings or bladder scrubbings.

The antibody may have a variety of different forms such as, but notlimited to, monoclonal, polyclonal, bispecific, chimeric, recombinant,anti-idiotypic, humanized, single-chain antibody molecule, orantigen-binding fragments thereof.

Examples of antibodies suitable for use in the disclosure include, butare not limited to, SCD-A7, 2D8, C-12, H-231, anti-telomerase catalyticsubunit, 10E9-2, 2C4, and tel 3 36-10. In an embodiment, the antibody isSCD-A7 or a telomerase binding fragment thereof.

The cancer can be any cancer where clinically relevant cells may bepresent which can result in an inconclusive cytological assessment forthe cancer. For example, the cancer can be an epithelial cancer. Otherexamples of cancers include, but are not necessarily limited to, bladdercancer, pancreatic cancer, liver cancer, gall bladder cancer, thyroidcancer, breast cancer, lung cancer, mesothelioma, cervical cancer,ovarian cancer, kidney cancer, lymphoma and colorectal cancer. In anembodiment the cancer is bladder cancer.

In a further aspect the present disclosure provides a method ofresolving an inconclusive cytological assessment of bladder epithelialcells in a urine sample obtained from a patient, the method comprisingcontacting epithelial cells from the sample with an anti-telomeraseantibody and performing a cytological assessment of the epithelial cellsto detect binding of the antibody to the epithelial cells, whereinbinding of the antibody to the epithelial cells indicates the presenceof malignant cells.

In a further aspect the present disclosure provides a method ofdetermining whether a subject has bladder cancer when a cytologicalassessment of bladder epithelial cell morphology that is inconclusivefor bladder cancer, the method comprising:

i) contacting a sample of bladder epithelial cells from the subject withan anti-telomerase antibody;

ii) performing a cytological assessment of the bladder epithelial cellsto detect binding of the antibody to the bladder epithelial cells;

wherein binding of the antibody to one or more bladder epithelial cellsin the sample indicates that the subject has cancer.

In a further aspect the present disclosure provides a method ofdetermining whether a subject has bladder cancer, the method comprising:

i) performing a cytological assessment of cell morphology on a sample ofbladder epithelial cells from the subject to determine the morphology ofone or more bladder epithelial cells in the sample;

ii) contacting a sample of bladder epithelial cells from the subjectwith an anti-telomerase antibody and performing a cytological assessmentof the bladder epithelial cells to detect binding of the antibody to thebladder epithelial cells;

wherein when the cytological assessment of cell morphology isinconclusive for bladder cancer, binding of the antibody to one or morebladder epithelial cells indicates that the subject has cancer.

In a further aspect, the present disclosure provides a method ofresolving an inconclusive cytological assessment of bladder epithelialcells in a urine sample obtained from a patient, the method comprisingcontacting a patient sample comprising bladder epithelial cells ofinconclusive cytology with an anti-telomerase antibody and detecting thepresence or absence of binding of the antibody to the bladder epithelialcells of inconclusive cytology, wherein binding of the antibody tobladder epithelial cells of inconclusive cytology indicates the presenceof malignant cells.

In an embodiment the bladder epithelial cells are bladder urothelialcells.

The present disclosure is not to be limited in scope by the specificembodiments described herein, which are intended for the purpose ofexemplification only. Functionally-equivalent products, compositions andmethods are clearly within the scope of the disclosure, as describedherein.

Throughout this specification, unless specifically stated otherwise orthe context requires otherwise, reference to a single step, compositionof matter, group of steps or group of compositions of matter shall betaken to encompass one and a plurality (i.e. one or more) of thosesteps, compositions of matter, groups of steps or group of compositionsof matter.

The disclosure is hereinafter described by way of the followingnon-limiting Examples and with reference to the accompanying figures.

BRIEF DESCRIPTION OF THE ACCOMPANYING DRAWINGS

FIG. 1: No cellular staining was observed in sample WH11-107 (clinicallynegative; FIG. 1A). First evidence of immunostaining of telomerase andits clinical correlation shown in clinically positive sample WH11-122using the anti-hTERT (Clone 2C4) antibody (FIG. 1B). Positive nuclearstaining was observed in 40-75% of the urothelial cells present, underoptimal antibody concentrations.

FIG. 2: Positive and negative cell types observed in high grade (Panel Aand B) and low grade (Panel C and D) clinical samples. Atypicalurothelial cells stained nuclear positive by telomerase immunostaining(Panel A and B). Cytologically normal looking urothelial cells stainednuclear positive by telomerase immunostaining (Panel C) and within thesame sample unstained cytologically normal looking urothelial cells(Panel D, inset arrow).

FIG. 3: Cells stained for telomerase hTERT protein from a clinicalsample of a patient with low grade (G1) bladder cancer. Panel A:Squamous cell (not from bladder); Panel B: Normal bladder cells (andsmall brown blood cell); Panel C: Normal-looking bladder cell positivefor Sienna test; Panel D: Cytologically abnormal bladder cell positivefor telomerase immunostaining.

DETAILED DESCRIPTION OF THE INVENTION General Techniques and Definitions

Unless specifically defined otherwise, all technical and scientificterms used herein shall be taken to have the same meaning as commonlyunderstood by one of ordinary skill in the art (e.g., in cell culture,molecular genetics, cancer diagnostics, immunology,immunohistochemistry, protein chemistry, and biochemistry).

Unless otherwise indicated, the immunoassay, sample preparation, andimmunological techniques utilized in the present invention are standardprocedures, well known to those skilled in the art. Such techniques aredescribed and explained throughout the literature in sources such as, J.Perbal, A Practical Guide to Molecular Cloning, John Wiley and Sons(1984), J. Sambrook et al., Molecular Cloning: A Laboratory Manual, ColdSpring Harbour Laboratory Press (1989), T. A. Brown (editor), EssentialMolecular Biology: A Practical Approach, Volumes 1 and 2, IRL Press(1991), D. M. Glover and B. D. Hames (editors), DNA Cloning: A PracticalApproach, Volumes 1-4, IRL Press (1995 and 1996), and F. M. Ausubel etal. (editors), Current Protocols in Molecular Biology, Greene Pub.Associates and Wiley-Interscience (1988, including all updates untilpresent), Ed Harlow and David Lane (editors) Antibodies: A LaboratoryManual, Cold Spring Harbour Laboratory, (1988), and J. E. Coligan et al.(editors) Current Protocols in Immunology, John Wiley & Sons (includingall updates until present).

The term “and/or”, e.g., “X and/or Y” shall be understood to mean either“X and Y” or “X or Y” and shall be taken to provide explicit support forboth meanings or for either meaning.

As used herein, the term “about”, unless stated to the contrary, refersto +/−10%, more preferably +/−5%, more preferably +/−1%, more preferably+/−0.5% of the designated value.

Throughout this specification the word “comprise”, or variations such as“comprises” or “comprising”, will be understood to imply the inclusionof a stated element, integer or step, or group of elements, integers orsteps, but not the exclusion of any other element, integer or step, orgroup of elements, integers or steps.

Cytological Assessment

“Cytological assessment” of cell morphology in cancer diagnostics seeksto identify malignant cells based on morphologic characteristics.Cytological assessment of cell morphology is a procedure that is part ofthe standard of care and used alongside, or as a reflex to, furtherinvestigation for the detection of recurrence or the diagnosis ofcancer. It is not a test per se but a pathology consultation based on aparticular sample or sample set. The assessment procedure is complex andrequires expertise and care in sample collection to provide a correctassessment. In the context of bladder cancer, cytological assessment canbe used alongside, or as a reflex to, cystoscopy for the detection ofrecurrence or the diagnosis of bladder cancer.

In performing a cytological assessment of cell morphology, a cell sampleis typically fixed to a slide and viewed under a microscope to visuallyassess the morphology and cellular features. For example, bladderurothelial cells can be harvested from a urine sample, fixed to a slideand then visually assessed.

Before, visually assessing the slide, the sample may be stained toassist in visualising morphological changes to cells and cellularcomponents (e.g. nuclei). These stains can include a haematoxylin andeosin stain or Papanicolaou stain (Pap stain).

Historically, the performance of cytology was described as extremelygood with high-grade cancer but more recent studies have challenged thatperception. On the other hand, the majority of studies to date are ingeneral agreement regarding the low sensitivity of cytology in low gradecancer. Accordingly, cytological assessment can often be inconclusiveand not achieve its intended goal to aid in the diagnosis of cancer.Further, given the low sensitivity of cytological assessment, a negativeor inconclusive cytology result does not preclude the presence of cancer(especially low grade cancer).

Inconclusive Cytological Assessment of Cell Morphology

As used herein, an “inconclusive cytological assessment of cellmorphology” is inconclusive for cancer and therefore is not informativefor reaching a cancer diagnosis. More particularly, an “inconclusivecytological assessment of cell morphology” refers to an assessment thatidentifies cells that have lost their normal appearance but have notreached the level of abnormality of malignant cells.

Cells that have lost their normal appearance but have not reached thelevel of abnormality of malignant cells are commonly referred to in theart as cells with atypical or indeterminate cytology. Therefore, in thecontext of the present methods, an “inconclusive cytological assessmentof cell morphology” is one which reveals that one or more clinicallyrelevant cells in a sample obtained from the subject have atypical orindeterminate cytology.

Terms “atypical cytology” or “indeterminate cytology” can be usedinterchangeably to indicate an inconclusive cytological assessment. Inthe context of the present disclosure, cells with “atypical cytology”have lost their normal appearance but have not reached the level ofabnormality of malignant cells.

One of skill in the art would be aware of various morphological cuesthat indicate such cytology. An atypical call in cytology is determinedby one skilled in the art and indicates that they believe themorphological cues are sufficiently poorly defined so as to allow adefinitive call as either positive or negative by cytology. The call inthese cases will vary depending on the lab or the specialist, and mayinclude for example, “atypical” or “atypical cytology”, “atypia”,“indeterminate” or “indeterminate cytology”, “inconclusive” or“inconclusive cytology”, “equivocal” or “unknown”. Such calls areinconclusive cytological assessments.

Examples of atypical cytology features are provided below. “Atypical” or“atypia” are pathologic terms for a morphological abnormality in a cell.Morphological changes, at a cellular level, that may be associated withatypia and therefore, “atypical cytology” can include, densely stainednuclei, pleomorphic nuclei, altered nucleus:cytoplasm ratio, aberrantmitosis, frequent mitosis, supra-basal mitosis, de-differentiation, lossof cellular adhesion, loss of cellular polarity, apoptosis.

In cytological assessments for cancer, such as thyroid carcinoma, breastcancer or bladder cancer an inconclusive cytological assessment can bereported as “atypical cytology”.

For example, thyroid samples with a moderate amount of colloid andmoderate cellularity and/or, follicular cells present in groups showingsignificant crowding and overlapping can be difficult to classify aseither benign or malignant and therefore are often reported as“indeterminate”.

For many cancers, the cellular features associated “atypical cytology”can be dependent on the cytologist and their clinical practice. This canresult in, “atypical cytology” being divided into variousclassifications.

For example, various classifications associated with “atypical cytology”in thyroid carcinoma are exemplified in Table 1.

In bladder cancer, “atypical cytology” may be separated into low-gradeatypia or high-grade atypia. Histological features associated withlow-grade atypia in bladder cancer include, papilloma, papillaryhyperplasia and papillary urothelial neoplasm of low malignantpotential. Histological features associated with high-grade atypia inbladder cancer include atypia that falls short of carcinoma in situ butwith marked focal cytologic atypia and disorganised architecture.Histological features defined as atypical, that are also indicative ofHigh Grade Urothelial Carcinoma can include individual abnormal cells,hyperchromatic nuclei, irregular nuclear borders, increasednuclear:cytoplasm ratio, anisonucleosis, elongated nuclei and cellclusters.

TABLE 1 Exemplary features associated with “atypical cytology” forthyroid carcinoma. Cytology classification Features Atypical cellsMostly benign cells but including a few that are atypical in appearancewhere present malignancy is an unlikely possibility. Atypia of Prominentpopulation of micro follicles in an aspirate that does not otherwiseundetermined fulfil the criteria for “follicular neoplasm/suspicious forfollicular neoplasm. significance A more prominent than usual populationof micro follicles may occur (and may be disproportionately apparent ona minority of smears) in a moderately or markedly cellular sample, butthe overall proportion of micro follicles is not sufficient for adiagnosis of follicular neoplasm/suspicious for follicular neoplasm. Apredominance of Hürthle cells in a sparsely cellular aspirate with scantcolloid. Interpretation of follicular cell atypia is hindered by samplepreparation artefact. Moderately or markedly cellular sample is composedof a virtually exclusive population of Hürthle cells, yet the clinicalsetting suggests a benign Hürthle cell nodule. There are focal featuressuggestive of papillary carcinoma, including nuclear grooves, enlargednuclei with pale chromatin, and alterations in nuclear contour and shapein an otherwise predominantly benign-appearing sample. There arecyst-lining cells that may appear atypical owing to the presence ofnuclear grooves, prominent nucleoli, elongated nuclei and cytoplasm,and/or intranuclear cytoplasmic inclusions in an otherwise predominantlybenign appearing sample. A minor population of follicular cells shownuclear enlargement, often accompanied by prominent nucleoli. There isan atypical lymphoid infiltrate (in which a repeated aspirate for flowcytometry is desirable), but the degree of atypia is insufficient forthe general category “suspicious for malignancy”. Follicular Samplecontains cells with cytomorphologic features that distinguish them fromneoplasm/ benign follicular nodules. suspicious for Disturbedcytoarchitecture: follicular cells are arranged predominantly in microfollicular follicular or trabecular arrangements. neoplasm Cellularcrowding and overlapping with larger than normal follicular cells.Majority of the follicular cells are arranged in abnormal architecturalgroupings. Suspicious for Sample contains a few malignant-appearingcells which are poorly preserved, or malignancy too few cells forconfident diagnosis, or is obscured by inflammation, blood, or celldebris The sample is adequate and there are some features of malignancy,but it lacks overtly malignant cells The clinical history suggestscaution despite a few malignant-appearing cells present (e.g.,cavitating TB or bronchiectasis, viral cytopathic effect, andchemotherapy or radiotherapy effect) The smear background suggeststumour necrosis, although well-preserved malignant cells are notidentified The cytologic criteria of malignancy overlap with benignlesions

All of the categories described in Table 1 can be described as atypicaland indeterminate for cancer and therefore are not informative forreaching a cancer diagnosis. In the context of the present disclosure,these categories are an “inconclusive cytological assessment of cellmorphology”.

Resolving an Inconclusive Cytological Assessment of Cell Morphology

As used herein, the term “resolving” refers to the resolution of aninconclusive cytological assessment to determine the clinical status ofa sample. Previously, it has been difficult to resolve an inconclusivecytological assessment of cell morphology to identify malignant cellsand determine whether a subject has cancer. For example, it is typicallyreported by leading uropathology laboratories that 20-25% of all urinecytologies are inconclusive. However, this figure may vary between 10and 40% (Raab et al., 2007; Zaak et al., 2001; Schneeweiss et al.,1999). The use and accuracy of cytology is fundamental in conventionalpractice to diagnosis and subsequent management of bladder cancerpatients. Accordingly, resolving “inconclusive” cytologyical assessmentsto determine clinical status would be extremely valuable in up to 40% ofall cases.

It has now been found that an inconclusive cytological assessment on thebasis of morphology can be resolved to determine clinical status using atelomerase immunostaining test and further cytological assessment todetect binding of an anti-telomerase antibody to clinically relevantcells.

An advantage of this approach is that binding of an anti-telomeraseantibody can be detected in individual clinically relevant cells. Forexample, binding of an anti-telomerase antibody can be detected inindividual bladder urothelial cells obtained from a urine sample.

In particular, the present inventors have found that the binding of ananti-telomerase antibody to one or more clinically relevant cells in asample from a subject indicates that the subject has cancer. As would beappreciated by one of skill in the art, an indication of cancer alsoindicates the presence of malignant cells in the sample. In performingthe present method, telomerase can be present in more than oneclinically relevant cell and indicate that a subject has cancer. Invarious embodiments, binding of an anti-telomerase antibody to at leastabout 1, at least about 2, at least about 3, at least about 4, at leastabout 5, at least about 6, at least about 7, at least about 8, at leastabout 9, at least about 10, at least about 11, at least about 12, atleast about 13, at least about 14, at least about 15, at least about 20,at least about 30, at least about 40, at least about 50, at least about60, at least about 70, at least about 80, at least about 90, at leastabout 100, at least about 200 clinically relevant cells cytologicallyassessed in a sample from a subject indicates that the subject hascancer. In contrast, the absence of anti-telomerase antibody binding toclinically relevant cells indicates that malignant cells are not presentin the sample.

More particularly, the present inventors have found that the binding ofan anti-telomerase antibody to one or more clinically relevant cells ina sample with “atypical” cytology from a subject indicates that thesubject has cancer. In various embodiments, binding of ananti-telomerase antibody to at least about 1, at least about 2, at leastabout 3, at least about 4, at least about 5, at least about 6, at leastabout 7, at least about 8, at least about 9, at least about 10, at leastabout 11, at least about 12, at least about 13, at least about 14, atleast about 15, at least about 20, at least about 30, at least about 40,at least about 50, at least about 60, at least about 70, at least about80, at least about 90, at least about 100, at least about 200 clinicallyrelevant cells with “atypical” cytology in a sample from a subjectindicates that the subject has cancer. In contrast, the absence ofanti-telomerase antibody binding to clinically relevant cells with“atypical” cytology indicates that malignant cells are not present inthe sample.

Further, telomerase can be present in a percentage of the total numberof clinically relevant cells cytologically assessed and indicate that asubject has cancer. In various embodiments, binding of ananti-telomerase antibody to at least about 1%, at least about 2%, atleast about 3%, at least about 4%, at least about 5%, at least about 6%,at least about 7%, at least about 8%, at least about 9%, at least about10%, at least about 11%, at least about 12%, at least about 13%, atleast about 14%, at least about 15%, at least about 20%, at least about30%, at least about 40%, at least about 50%, at least about 60%, atleast about 70%, at least about 80%, at least about 90% of clinicallyrelevant cells cytologically assessed in a sample from a subjectindicates that the subject has cancer.

In one example, binding of an anti-telomerase antibody to at least about5% of clinically relevant cells cytologically assessed in a sample froma subject indicates that the subject has cancer. For the avoidance ofdoubt, it is envisaged that binding of an anti-telomerase antibody toone cell per 20 clinically relevant cells indicates that the subject hascancer.

In various embodiments, binding of an anti-telomerase antibody to atleast about 1%, at least about 2%, at least about 3%, at least about 4%,at least about 5%, at least about 6%, at least about 7%, at least about8%, at least about 9%, at least about 10%, at least about 11%, at leastabout 12%, at least about 13%, at least about 14%, at least about 15%,at least about 20%, at least about 30%, at least about 40%, at leastabout 50%, at least about 60%, at least about 70%, at least about 80%,at least about 90% of clinically relevant cells with “atypical” cytologyin a sample from a subject indicates that the subject has cancer.

Again, for the avoidance of doubt, it is envisaged that binding of ananti-telomerase antibody to one cell with “atypical” cytology per 20clinically relevant cells indicates that the subject has cancer.

In one example, binding of an anti-telomerase antibody to at least about5% of clinically relevant cells with atypical cytology cytologicallyassessed in a sample from a subject indicates that the subject hascancer.

In contrast, the absence of anti-telomerase antibody binding toclinically relevant cells indicates that the cells in the sample are notmalignant.

In some embodiments, the sensitivity and/or specificity are measuredagainst a clinical diagnosis of cancer.

In various embodiments, the sensitivity achieved by the presentlyclaimed method for prognosing or determining whether a subject hascancer is at least about 50%, at least about 60%, at least about 70%, atleast about 71%, at least about 72%, at least about 73%, at least about74%, at least about 75%, at least about 76%, at least about 77%, atleast about 78%, at least about 79%, at least about 80%, at least about81%, at least about 82%, at least about 83%, at least about 84%, atleast about 85%, at least about 86%, at least about 87%, at least about88%, at least about 89%, at least about 90%, at least about 91%, atleast about 92%, at least about 93%, at least about 94%, at least about95%.

In various embodiments, the specificity achieved by the presentlyclaimed method for prognosing or determining whether a subject hascancer is at least about 50%, at least about 60%, at least about 70%, atleast about 71%, at least about 72%, at least about 73%, at least about74%, at least about 75%, at least about 76%, at least about 77%, atleast about 78%, at least about 79%, at least about 80%, at least about81%, at least about 82%, at least about 83%, at least about 84%, atleast about 85%, at least about 86%, at least about 87%, at least about88%, at least about 89%, at least about 90%, at least about 91%, atleast about 92%, at least about 93%, at least about 94%, or at leastabout 95%.

Detecting Anti-Telomerase Antibody Binding

Telomerase is a naturally occurring enzyme that maintains the length oftelomeres at the end of a chromosome. In humans, telomerase isover-expressed in human stem cells, in germ line cells and in malignantcells. The function of telomerase is to synthesise new single strandedTTAGGG repeats at the end of each chromosome. In normal cells,telomerase plays a protective role by permitting a cell to multiply,thus preventing shortening of telomeres and avoiding cellular senescence(Bodnar et al., 1998). In contrast, albeit with the same mode of action,telomerase can also exhibit cancer-promoting properties in cells whichare or may become malignant. In the absence of senescence, cells(tumours) replicate indefinitely, thereby introducing and propagatingmutations (Blackburn et al., 2005). This cancer-promoting property oftelomerase aids the immortality of the cell and development of cancer.Its association to cancer is evident in that its presence is observed asa common feature in nearly all tumour cells.

The present disclosure seeks to resolve an inconclusive cytologicalassessment of cell morphology by detecting whether telomerase is presentin a sample. To detect telomerase, a cell sample from a subject iscontacted with an antibody that binds telomerase, also referred to as ananti-telomerase antibody. It is considered that terms such as‘contacting’, ‘exposing’ or ‘applying’ are terms that can, in context,be used interchangeably in the present disclosure. The term contacting,requires that the anti-telomerase antibody be brought into contact witha cell sample to detect whether telomerase is present in one or morecells in the sample. The binding of an antibody to telomerase indicatesthat telomerase is present in the cell. Further, the presence oftelomerase in a sample may also be referred to as telomerase positive orpositive for telomerase. The binding of an antibody to telomerase isdetected via cytological assessment. For example, a light microscope maybe used to detect binding of an antibody to telomerase in a clinicallyrelevant cell.

Detecting the binding of an anti-telomerase antibody to clinicallyrelevant cells in methods of the disclosure may be accomplished by anyantibody/antigen binding detection technique known in the art wherebinding of the antibody to the antigen in clinically relevant cells canbe detected via cytological assessment. For example, an immunoassayincorporating an anti-telomerase antibody may be used. In this example,cytology is used to detect binding of the anti-telomerase antibody totelomerase. In methods of the disclosure, telomerase is the “antigen”.It is also envisaged that telomerase detection methods may beincorporated into an automated telomerase detection system. Such anautomated immunoassay system would provide for the automatic processingof a sample and cytological detection of telomerase. It is envisagedthat such a system would allow high throughput analysis of telomerase insamples.

Immunoassay

For routine clinical assessment it is envisaged that methods based on animmunoassay format will be used to detect the presence of telomerase ina sample. In the context of the present disclosure, an immunoassay is abiochemical test that measures the presence or concentration of anantigen in a solution through the use of an antibody or immunoglobulin.

The antibody used in the present disclosure can be any antibody that candetect whether telomerase is present in one or more cells in the sample.Various commercially available antibodies that can detect whethertelomerase is present in a cell are available for use in the methods ofthe disclosure. Such antibodies can be obtained from SapphireBiosciences, Life Span Biosciences, Novus Biologicals, AustralianBiosearch, Epitomics, Santa Cruz, EMD Millipore, GenWay Biotech Inc,Jomar Biosciences, Sigma-Aldrich, BioCore Pty Ltd, US Biologicals,Thermo Scientific, Life Research, Resolving Images, Leica microsystemsand Sienna Cancer Diagnostics Ltd. In an example, the antibody binds thetelomerase complex (including each of human telomerase reversetranscriptase, telomerase RNA (TR or TERC), and dyskerin (DKC1) and/orTelomerase reverse transcriptase (hTERT). Preferably, the antibody is ananti-hTERT antibody. Most preferably, the antibody that binds telomeraseis SCD-A7, 2D8, C-12, H-231, anti-telomerase catalytic subunit, 10E9-2,2C4, and tel 3 36-10.

These antibodies are known in the art. For example, the anti-hTERT (tel3) antibody is a monoclonal antibody produced from the hybridoma clone,36-10. To purify the antibody, the IgG fraction of ascites was purifiedby Protein G affinity chromatography. The anti-hTERT (Clone SCD-A7)antibody is an IgM mAb, produced from the hybridoma clone, HJ123-2C4(Masutomi et al., 2003) grown in hollow fibre cultures. In producingthis antibody, amino-terminal FLAG epitope-tagged hTERT purified frombaculovirus vector-infected insect cells was used as an immunogen tostimulate the production of anti-hTERT Clone SCD-A7 mAb.

The anti-hTERT (Clone 2C4) antibody is described in (Masutomi et al.,2003). In producing this antibody, amino-terminal FLAG epitope-taggedhTERT purified from baculovirus vector-infected insect cells was used asan immunogen to stimulate the production of anti-hTERT Clone 2C4 mAb.2C4 is an IgM mAb, produced from the hybridoma clone, HJ123-2C4 grown inhollow fibre cultures.

Antibodies used in the methods of the present disclosure are alsocommercially available such as 2D8 (Novus NB100-297), C-12 (Santa Cruz377511), H-231 (Santa Cruz 7212), anti-telomerase catalytic subunit(Rockland 600-401-252), 10E9-2 (MBL M216-3), 2C4 (Novus NB100-317),SCD-A7 (Sienna Cancer Diagnostics P/N 01-5001).

In an example, the antibodies of the present disclosure are detectablylabelled. Examples of detectable labels include the conjugation of adye, fluorophore or other reporter molecule for assays, tracking orimaging.

The antibody used in the present disclosure is not limited to monovalentantibodies and multivalent antibodies represented by IgM but alsoincludes bivalent antibodies represented by IgG, so long as they bindtelomerase.

Further, the antibody used in the present disclosure is not limited towhole antibody molecules, but includes minibodies, diabodies andmodified products thereof, so long as they bind telomerase.

A minibody comprises antibody fragments lacking a portion of a wholeantibody (for example, whole IgG), and is not particularly limited solong as it has telomerase-binding ability. With the exception oftelomerase binding ability, there are no particular limitations on theantibody fragments of the present disclosure, so long as they areportions of a whole antibody, but they preferably contain a heavy chainvariable region (VH) and/or a light chain variable region (VL).Furthermore, as long as it has telomerase antigen-binding ability, partof VH and/or VL can be deleted. The variable region may be chimerized orhumanized. Specific examples of the antibody fragments include Fab,Fab′, F(ab′)2, and Fv. Specific examples of minibodies include Fab,Fab′, F(ab′)2, Fv, scFv (single chain Fv), diabody, and sc(Fv)2 (singlechain (Fv)2). Multimers of these antibodies (for example, dimers,trimers, tetramers, and polymers) are also included in the minibodiesthat can be used to detect telomerase.

A diabody is a dimer composed of two polypeptide chains, and generally,the polypeptide chains are individually linked by a linker of, forexample, five residues or so, which is short enough to prevent bindingbetween VL and VH in the same chain. VL and VH that are encoded by thesame polypeptide chain have a short linker between them, and form adimer because they cannot form a single chain variable region fragment.Therefore, diabodies have two antigen binding sites.

Preferably, the antibody that binds telomerase is monoclonal,polyclonal, bispecific, chimeric, recombinant, anti-idiotypic,humanized, single-chain antibody molecule, or antigen-binding fragmentsthereof.

In a preferred embodiment according to the present disclosure the methodfor detection of telomerase uses a telomerase-specific primary antibody.Binding of the primary antibody to telomerase can be visualised viavarious known methods. For example, a labelled secondary antibody thatrecognises the primary antibody could be used. In this example, thelabel could be an enzyme such as horse radish peroxidase, a radioactiveisotope, a fluorescent reporter, an electrochemiluminescent tag. Bindingof the labelled secondary antibody to the primary antibody would bedetected via cytological assessment.

In a particular example, a sample is contacted with atelomerase-specific primary anti-hTERT antibody. The sample is thenwashed to remove any unbound primary antibody and then a secondaryantibody specific for the primary antibody and linked to a peroxidaseenzyme is applied to the sample. The sample is then washed to remove anyunbound secondary antibody and 3,3′-Diaminobenzidine (DAB) is applied tothe sample. The conversion of DAB into a coloured product is visualisedby routine cytological assessment with the presence of a colouredproduct indicating that telomerase is present in the sample.

Cancer Types

In the claimed method, the cancer may be any cancer so long as thesubject cancer cells express telomerase. Preferably the cancer isbladder cancer, pancreatic cancer, liver cancer, gall bladder cancer,thyroid cancer, breast cancer, lung cancer, mesothelioma, cervicalcancer, ovarian cancer, kidney cancer, colorectal cancer, lymphoma. Mostpreferably, the cancer is bladder cancer.

As would be appreciated by one of skill in the art, each cancer type hasvarious characteristics associated with cancer grade. These grades aregenerally dictated by the level of cancer spread or invasion into thesurrounding tissues. For example, the later grades of cancer or “highgrade” is generally associated with a higher potential for metastasisand a poorer prognosis. High grade cancers have generally spread fromthe tissue or organ of origin into the surrounding tissue or throughoutthe body. In contrast, “low grade” cancer can be characterized ascarcinoma in situ (CIS) meaning that cells are abnormally proliferatingbut are still contained within the tissue or organ of origin.

In the context of bladder cancer, “High grade” or “higher grade” bladdercancer refers to a bladder cancer that is more likely to recur and/orprogress and/or become invasive in a subject, including malignantcancers with higher potential for metastasis (bladder cancer that isconsidered to be more aggressive). Cancers that are not confined to thebladder (i.e. muscle-invasive bladder cancer) are considered to be moreaggressive bladder cancers.

Low grades of bladder cancer can be characterized as carcinoma in situ(CIS) meaning that cells are abnormally proliferating but are stillcontained within the bladder. “Low grade” or “lower grade” bladdercancer refers to bladder cancer, including malignant cancers with lowerpotential for recurrence, progression, invasion and/or metastasis (i.e.bladder cancer that is considered to be less aggressive). Cancers thatare confined to the bladder (i.e. non-muscle invasive bladder cancer,NMIBC) are considered to be less aggressive bladder cancer.

Low grade bladder cancer may be classified as benign. Benign bladdercancer constitutes a mass of cells that at the time of diagnosis lacksthe ability to invade neighbouring tissue or metastasize. Benign bladdercancers generally have a slower growth rate than malignant cancers andthe benign cells are usually well differentiated.

It is envisaged the present disclosure can be used to determine whethera subject has low grade cancer.

Sample Preparation and Analysis

In performing the methods of the disclosure a cell sample from a subjectis required. As used herein, the term “sample” refers to a cell orpopulation of cells or a quantity of tissue or fluid from a subject.Most often, the sample has been removed from a subject. The ‘sample’includes extracts and/or derivatives and/or fractions of the sample. Itis considered that terms such as ‘sample’ and ‘specimen’ are terms thatcan, in context, be used interchangeably in the present disclosure. Inthe present disclosure, any biological material can be used as theabove-mentioned sample so long as it can be collected from the subject.It is contemplated that the sample used in the present disclosure be abiological sample from a human.

The sample may include material obtained from biopsy or resection.Preferably, the sample is a fluid sample. The fluid sample may include avariety of biological materials selected from but not limited to thegroup consisting of blood (including whole blood), blood plasma, bloodserum, hemolysate, lymph, synovial fluid, spinal fluid, urine, bladderwashings, bladder scrubbings, cerebrospinal fluid, semen, stool, sputum,mucus, amniotic fluid, lacrimal fluid, cyst fluid, sweat glandsecretion, bile, milk, tears or saliva. In the context of bladdercancer, the fluid sample is a urine sample.

It is envisaged that samples used in the methods of the presentdisclosure can be obtained using techniques known in the art. Forexample, in the context of bladder cancer, biopsy and resection materialcan be obtained via cytoscopy. In the context of breast or thyroidcancer, the sample may be obtained via fine needle aspiration.Alternatively, bladder urothelial cells may be obtained from a urinesample supplied by a subject.

In one example, a sample used in the methods of the present disclosureis a patient sample comprising clinically relevant cells of inconclusivecytology. In this example, the clinically relevant cells of inconclusivecytology are identified before contacting the sample with ananti-telomerase antibody and detecting the presence or absence ofbinding of the antibody to the clinically relevant cells of inconclusivecytology.

It is envisaged that in performing the present method the cytologicalassessment of cell morphology and the cytological assessment fordetection of telomerase may be performed on separate samples obtainedfrom the same patient. For example, a subject may provide two sampleswith one being sent for cytological assessment of cell morphology andthe other for cytological assessment for detection of telomerase. Inthis example, a cytological assessment of cell morphology that isinconclusive for cancer can be resolved by cytological assessment fordetection of telomerase, with the detection of telomerase in clinicallyrelevant cells indicating that the subject has cancer.

However, in a clinical setting, obtaining an additional sample forfurther testing, e.g., from a patient whose cytological assessment ofcell morphology revealed that one or more clinically relevant cells inthe sample had an atypical cytological assessment for cell morphology,can be difficult and can delay further testing that is desirable.Further, when additional specimens need to be processed prior totesting, it is desirable to minimize the costs associated withprocessing (e.g., reagents, and the like).

Accordingly, it is preferable that the cytological assessment of cellmorphology and the cytological assessment for detection of telomerase beperformed on the same sample obtained from the subject.

It is envisaged that that the present method may be performed bypreparing two separate slides with cells from the same sample. In thisinstance, one slide is sent for cytological assessment of cellmorphology and the other for cytological assessment for detection oftelomerase. The methods discussed below in Example 2 may be used toprepare slides.

The present inventors have found that when a cytological assessment ofcell morphology is inconclusive for cancer, the binding of ananti-telomerase antibody to these cells indicates that the subject hascancer. Accordingly, it is preferable that the same slide be used forcytological assessment of cell morphology and the cytological assessmentfor detection of telomerase.

Clinically Relevant Cells

The phrase “clinically relevant cells” refers to those cells that thecytologist or cytopathologist is examining to determine the cancerstatus of the patient.

Clinically relevant cells will depend on the cancer being investigatedand in the context of the present disclosure can include, ductal andlobular cells of the breast, respiratory cells of the lung, mucosalcells of the digestive tract, duct and islet cells of the pancreas,hepatocytes, follicular cells, mesothelial cells, germ cells, granulosacells and epithelial cells of the ovary, glandular and basal cells ofthe prostate, epithelial cells of the ureter, urothelial cells, ductaland tubular cells of the kidney, endometrial cells.

The determination of cancer can be made because of the general principlethat normal cells do not express telomerase while malignant cellsexpress telomerase. However, as would be appreciated by one of skill inthe art, there are exceptions to this general principle as certainnon-malignant cell types also express telomerase. These cells are notconsidered clinically relevant and should be excluded from theassessment. Preferably, the excluded cells are selected from the groupcomprising, T-cells, B-cells, neutrophils, macrophages, granulocytes,dendritic cells, mast cells, memory-cells, plasma cells, eosinophils,seminal vesicle cells, sperm. Most preferably, the excluded cells areneutrophils, macrophages and eosinophils, seminal vesicle cells andsperm. These cells are not clinically relevant to the assessment ofcancer and have a distinctly different morphology from clinicallyrelevant cells and therefore can easily be excluded visually whenperforming the cytological assessment.

For example, when using the present methods to determine bladder cancer,there are several cell types which one of skill in the art wouldvisually exclude from the cytological analysis. These cells includeinflammatory cells such as neutrophils, macrophages and eosinophils, aswell as renal tubular cells, seminal vesicle cells, sperm, and squamouscells. These cells are not clinically relevant to the assessment ofbladder cancer and have a distinctly different morphology fromclinically relevant normal urothelial cells (bladder wall cells) andtherefore can easily be excluded visually when performing thecytological assessment.

Reflexive Testing

It is envisaged that the claimed method may be performed as a reflexivetest. A “reflexive test” refers to a subsequent test (e.g., a secondtest) that is undertaken based upon the results obtained in a previoustest (e.g., a first test). When determining whether a subject hascancer, cytological assessment of a sample can lead to a desire to testfor another target. In the context of the present disclosure, the desireto test for another target (i.e. detect binding of an anti-telomeraseantibody to clinically relevant cells) is driven by a cytologicalassessment of cell morphology that is inconclusive for the cancer whichreveals one or more atypical cells in a sample.

Adjunctive Testing

It is also envisaged that the claimed method may be performed as anadjunctive test. A test that provides information that adds to orassists in the interpretation of the results of other tests, andprovides information useful for resolving an inconclusive earlierassessment may be classified as an adjunctive test. In a clinicalsetting, a cytological assessment of cell morphology may be requested todetermine whether a subject has cancer. However, the cytologicalassessment may be inconclusive for the cancer. Therefore, to assist indetermining whether the subject has cancer, a further cytologicalassessment is performed to detect the binding of an anti-telomeraseantibody to clinically relevant cells in a sample from the subject as anadjunct to the cytological assessment of cell morphology. In thiscontext, the binding of an anti-telomerase antibody to one or moreclinically relevant cells indicates that the subject has cancer,resolving the inconclusive cytological assessment of cell morphology.

In performing adjunctive testing it is envisaged that the cytologicalassessment of cell morphology can be performed at or about the same timeas the cytological detection of telomerase. However, these steps may beperformed separately.

Subjects

As used herein, the “subject” can be any organism which can have cancer.In a preferred embodiment, the subject is a mammal. The mammal may be acompanion animal such as a dog or cat, or a livestock animal such as ahorse or cow. In an embodiment, the subject is a human. Terms such as‘subject’, ‘patient’ or ‘individual’ are terms that can, in context, beused interchangeably in the present disclosure.

If malignant cells are identified in a subject using the methods of thepresent disclosure the subject can be directed or prescribed treatmentfor cancer. For example, if bladder cancer is identified in a subject,the subject may be directed treatments such as surgical interventionsuch as cystectomy, chemotherapy, radiotherapy, immunotherapy, antibodytherapy or combinations thereof.

It is envisaged that the method of the present disclosure can be used todetermine whether any subject has cancer. Preferably, the method is usedto determine cancer in a subject with symptoms that are indicative ofcancer. For example, in the context of bladder cancer, the presentmethod would be applicable to a subject presenting to the clinic withsymptoms indicative of bladder disease such as haematuria (blood in theurine); urinary frequency urgency; burning sensation on urination.

A sample used in the present disclosure may also be obtained from asubject requiring regular surveillance to monitor for new or recurrentcancer. For example, cancer survivors may require regular surveillanceto monitor for new or recurrent lesions. Clinicians presently rely onmorphologic changes in samples recovered from these patients. Once anabnormal cytological assessment of cell morphology is identified in asample, the patient undergoes further investigation to obtain anothercytology sample and/or biopsy to identify and confirm the source of thefirst abnormal cell population. If cancer is identified, the patient ismanaged by a surgical procedure and/or intravesical chemotherapy orimmunotherapy to eradicate the malignant cells. If a cytologicalassessment of cell morphology is inconclusive for cancer, a cliniciancan obtain a sample from the subject under surveillance and apply thepresent method to determine whether they have cancer. If cancer isdetermined, the patient can then undergo further investigation toconfirm the source of the telomerase positive cell population.

In the context of bladder cancer, surveillance after treatment beginswith urinary cytological assessment of cell morphology every 3 monthsfor one to two years, depending on the patient's risk factors and cancerstaging. Screening intervals for cytological assessment of cellmorphology are extended, depending on previous cellular and cystoscopicfindings. It is envisaged that cytological assessment to detect thebinding of an anti-telomerase antibody to clinically relevant cellswould be paired with the above referenced cytology surveillance regimen.If an inconclusive cytological assessment of cell morphology is resolvedby detecting binding of an anti-telomerase antibody to clinicallyrelevant cells, the patient can then undergo cytoscopy to confirm thesource of the telomerase positive cell population.

Diagnostic Determination

It is envisaged that in performing the claimed method particular resultsfor cytological assessment of telomerase and cytological assessment ofcell morphology will be associated with a specific diagnosticdetermination for each subject. The telomerase and cell morphologyresults that may be obtained when performing the claimed method aresummarised below in Table 2.

TABLE 2 Diagnostic determination and clinical outcome associated withcytological assessment of cell morphology and cytological assessment oftelomerase results Cytological Cytological Assessment Assessment of ofcell Diagnostic determination Telomerase morphology and Clincial Outcome+ve +ve Positive telomerase and cytology results indicates the subjecthas cancer. Cystoscopic investigation or upper tract imaging iswarranted. +ve −ve Positive telomerase result indicates the subject hascancer. Cystoscopic investigation or upper tract imaging is warranted.+ve atypical Positive telomerase result indicates the subject hascancer. Cystoscopic investigation or upper tract imaging is warranted−ve +ve The high positive predictive value and specificity of cytologyof cell morphology alone suggests subject has cancer. Cystoscopicinvestigation or upper tract imaging is warranted −ve −ve Subject isdisease free. −ve atypical Subject potentially has benign/reactivechanges which are not linked to cancer.

The following results indicate that the subject has cancer and thereforecystoscopic investigation or upper tract imaging is warranted:

-   -   The binding of an anti-telomerase antibody to clinically        relevant cells and positive cytological assessment of cell        morphology    -   The binding of an anti-telomerase antibody to clinically        relevant cells and negative cytological assessment of cell        morphology    -   The binding of an anti-telomerase antibody to clinically        relevant cells and an inconclusive cytological assessment of        cell morphology    -   Although unlikely to occur given the matching sensitivities of        both positive cytological assessment of cell morphology and the        binding of an anti-telomerase antibody to clinically relevant        cells; the absence of anti-telomerase antibody binding to        clinically relevant cells and positive cytological assessment of        cell morphology.

The absence of anti-telomerase antibody binding to clinically relevantcells and negative cytological assessment of cell morphology indicatesthat the cells in the sample are not malignant. Further, the absence ofanti-telomerase antibody binding to clinically relevant cells and aninconclusive cytological assessment of cell morphology indicates thatthe subject potentially has benign/reactive changes which are not linkedto cancer. Accordingly, further investigation via cystoscopy is notwarranted.

In the context of the present disclosure, positive cytologicalassessment of cell morphology refers to the identification of cellshaving morphological changes indicative of cancer. Morphological changesthat may be associated with cancer include enlarged nuclei withirregular size and shape, prominent nucleoli, scarce cytoplasm which maybe intense or pale in colour. In contrast, negative cytologicalassessment of cell morphology is defined as the absence of anymorphological changes indicative of atypia, or cancer.

Definitive Diagnosis

In applying the methods of the present disclosure to resolve aninconclusive cytological assessment for cancer and determine theclinical status of a sample whether a subject has cancer, it isconsidered that a diagnostic determination regarding the presence of acancer can be made based on the binding of an anti-telomerase antibodyto one or more clinically relevant cells from a cell sample obtainedfrom a subject. However, the diagnostic determination may or may not beconclusive with respect to the definitive diagnosis upon which atreating physician will determine a course of treatment. Put anotherway, a diagnostic determination obtained using the techniques of thedisclosure would be understood by one skilled in the art to refer to theprocess of attempting to determine or identify a possible cancer.

The methods of the present disclosure can be used in providingassistance in assessing the risk of cancer development and would beconsidered to assist in making an assessment of a pre-clinicaldetermination regarding the presence, or nature, of a predisposition orprecursor to cancer. This would be considered to refer to making afinding that a subject has a significantly enhanced probability ofdeveloping cancer.

It would be contemplated that the methods of the present disclosurecould also be used in combination with other methods of clinicalassessment of cancer known in the art in providing an evaluation of thepresence of cancer or an increased risk of cancer.

The definitive diagnosis of the cancer status of a subject determined tohave cancer can be validated or confirmed if warranted, such as throughimaging techniques including, PET, MRI, ultrasound, CT, PET/CT.Accordingly, the methods of the present disclosure can be used in apre-screening or prognostic manner to assess whether a subject hascancer, and if warranted, a further definitive diagnosis can beconducted. In the context of the bladder cancer, investigation viacystoscopy with biopsy or upper tract imaging would be used to obtain adefinitive diagnosis of the cancer status. It is also envisaged that themethods of the present disclosure may be useful for selecting patientsfor clinical assessment using previously validated diagnostic tests, inparticular assessment via cystoscopy.

EXAMPLES Example 1: Clinical Samples

An ethics-controlled and approved proof of concept study on clinicalmaterial from urological patients suspected of having, or with a historyof, bladder cancer (urothelial cell carcinoma) was performed in order todemonstrate the clinical diagnostic potential of telomerase hTERTprotein immunostaining. Furthermore, the study aimed to demonstrate thathTERT immunostaining can differentiate samples obtained from low gradeversus high grade patients.

In this study, clinically positive patients had biopsy proven bladdercancer (including both non-invasive and muscle-invasive). All stage andgrade determinations were by histology. In the case where a patient hadmultiple bladder cancer foci at different stages/grades, the higherstage/grade was recorded.

Clinically negative patients were all asymptomatic individuals in goodhealth with no history of genitourinary disease or all disease-freepatients presenting, for the first time or under monitoring for priorbladder cancer, for the visual inspection of the bladder wall (byflexible/rigid cystoscopy).

A patient was excluded from the study if any of the following criteriawere met:

-   -   a) the patient had suspicious/uncharacterised non-bladder cancer        diagnosis on visual inspection (flexible/rigid cystoscopy) with        no histology performed;    -   b) monitoring patients that had a radical cystectomy;    -   c) patients with adenocarcinomas and non-urothelial bladder        cancers (including small cell carcinoma, carcinosarcoma, primary        lymphoma, and sarcoma; and/or    -   d) patients with other genitourinary tumours (kidney, prostate,        upper ureter).

A total of 253 samples were originally tested. Of these, 108 sampleswere assessed using the protocol outlined below in Example 2 where aform of epitope retrieval was used either by freeze thaw orheat-induced. Of those, 90 samples had at least one urothelial (bladderwall) cell present. The remaining 18 samples were removed from allfurther analyses since no relevant bladder cell wall cells (i.e.:urothelial cells) were found. Of those 90 samples, five clinicallypositive samples were removed from further analysis due to the lack ofbiopsy-proven disease. The remaining 85 samples are represented in Table3 (all clinically positive samples—biopsy-proven) and Table 4 (allclinically negative samples—cystoscopically clear), with cytologicalassessment of cell morphology and telomerase immunostain results shownfor each. For the eighty-five samples analysed, the number of clinicallyrelevant cells ranged from 5 to 3000 in both clinically positive andnegative patients.

-   -   Clinically negative samples: Range 5-900 urothelial cells.    -   Clinically positive samples: Range 10-3000 urothelial cells.

For all patients, telomerase immunostaining and parallel-cytologicalassessment of cell morphology on the same sample was performed and theresults recorded. Telomerase hTERT protein immunostaining andcytological assessment of cell morphology was performed blind of eachother and blind of clinical status (obtained by cystoscopy+/−biopsy).Immunostaining, cytological assessment of cell morphology and cystoscopywere all performed by trained clinicians and/or pathologists, registeredto perform these assays in their respective clinico-diagnostic and/ormedical fields.

Scoring of the telomerase immunostaining was determined by a cytologistwho scanned an adequate number of fields of view to obtain a confidentassessment of the slide. The number/percentage of urothelial cellsdisplaying nuclear staining was recorded by the reading cytologist. Acut-off value for test positivity was set at >5% of urothelial cellsshowing nuclear staining.

All samples (both clinically positive and negative) that were classifiedas atypical after cytological assessment of cell morphology are given inTable 5.

Example 2: Collection and Processing of Samples

Voided urine from patients was either processed immediately, ormaintained at 4° C. for a period no longer than 4-6 hours prior toprocessing. Samples were transferred into sterile 50 mL centrifuge tubesand centrifuged at 600 g for 10 minutes at 4° C. The tubes were removedand the supernatant discarded. Cell pellets were resuspended in 15 mL1×PBS and transferred into sterile 15 mL centrifuge tubes. Samples werere-centrifuged at 600 g for 10 minutes at 4° C. and the supernatantagain discarded. Cell pellets were finally resuspended in 1 ml 1×PBSprior to cell counting.

Approximately 30,000 cells per sample were transferred to sterile 15 mLcentrifuge tubes and the volume adjusted to 10 mL with Shandon CytospinCollection Fluid (Thermo Scientific, Ref No: 6768001, Lot No: 226955).Tubes were again centrifuged at 600 g for 10 minutes at 4° C. Thesupernatant was discarded prior to resuspending in Shandon CytospinCollection Fluid at a ratio of 250 μL per 30,000 cells. A ShandonCytospin 4 (Thermo Scientific, Part No: A778300101, Serial No: CY66951055) was used to affix the cells to glass microscope slides bycentrifuging the cells at 1000 rpm for 4 minutes with low acceleration.

Slides with affixed cells were stored in a microscope slide box at 4° C.overnight before transferring the slides into the −20° C. freezer.

All staining results reported herein were performed on Ventana BenchmarkXT or Ventana Benchmark Ultra automated staining platforms. Identicalresults have been obtained, after optimisation, on other automatedstaining platforms including, but not limited to, Leica Bond and BiocareintelliPATH FLX. In addition to automated staining platforms, identicalresults have also been obtained, after optimisation, using a manualimmuno staining process.

For the manual immunostaining process, slides were post-fixed in cold50% acetone: methanol for 10 minutes. Slides were washed in 1× Phosphatebuffered saline (PBS), pH 7.4, (Catalogue Number: 10010-023, 5×500 mLGibco® by Life Technologies) to remove residual fixative and then placedin a staining dish containing citrate buffer pH 6.0. The slides aretreated to a manual form of antigen retrieval for 30 minutes at 95° C.in a microwave oven. Slides are again washed in 1×PBS, pH 7.4. Postretrieval, slides were blocked with 5% BSA in 1×PBS with 0.5% Tween 20for 1 hour, prior to incubating with the telomerase-specific primaryanti-hTERT antibody at room temperature for 2 hours and washed in 1×PBSwith 0.5% Tween 20. Slides are treated with a post-primary antibodyblock, Novacastra Post Primary (Ref: RE7159, Lot #6012593, 125 mL, LeicaMicrosystems) for 1 hour at room temperature and again washed in 1×PBSwith 0.5% Tween 20. Slides are incubated with the secondary antibodyNovacastra Novolink Polymer (Ref: RE7161, Lot #6012594, 125 mL, LeicaMicrosystems) for 30 minutes at room temperature and washed in 1×PBSwith 0.5% Tween 20 prior to incubating with 3,3′-Diaminobenzidine (DAB)enhanced liquid substrate (Product Number: D3939, Sigma) for 2 minutesat room temperature. Slides are rinsed in 1×PBS, pH 7.4 to stop thereaction. Slides are then incubated in 0.5% Methyl Green solution at 60°C. for 5 minutes (Product Code: M8884-25G, Lot #MKBD8768V, 25 g, Sigma)and washed in tap water. Slides are dehydrated 0.05% (v/v) glacialacetic acid in acetone, then 95% ethanol, 100% ethanol followed by afinal step in xylene. Slides are mounted with Ultramount No: 4 MountingMedia (Product Code: II065C, Batch #1305141450, 100 mL) and immediatelya coverslip is applied before drying for 1 hour. Slides are observedunder a light microscope.

For the automated immunostaining process, slides were post-fixed in cold50% acetone: methanol for 10 minutes. Slides were washed/dipped inVentana Antibody Dilution Buffer (Ventana Medical Systems, Inc Cat No:ADB250) to remove residual fixative and then placed on the automatedstaining platform and antigen retrieved on-board at 95° C. for 8minutes. Post retrieval, slides were blocked with Ventana Discoveryreagent (Ventana Medical Systems, Inc, Cat No: 760-108) for 4 minutes,prior to incubating with the telomerase-specific primary anti-hTERTantibody at 36° C. for 32 minutes. The remaining steps relied onstandard Ventana platform settings using Ventana Discovery and VentanaUltraView Universal DAB Detection Kit (Ventana Medical Systems Inc, CatNo: 760-500). Hematoxylin counterstaining was performed off-board in astandard dip-dunk stainer. Counter staining could also be performedon-board to obtain identical results.

The results herein were obtained using the anti-hTERT (Clone 2C4)antibody described in (Masutomi et al., 2003).

TABLE 3 Cytological assessment of cell morphology and telomeraseimmunostain results in clinically positive samples (biopsy proven).Immunostaining result Cytological assessment % Urothelial # ID of cellmorphology* Test result cells stained 1 WH12-263^({circumflex over ( )})Benign Positive 80 2 AUA12-055 Positive Positive 45 3 WH12-278 PositivePositive 12.5 4 AUA12-057 Atypical Positive 10 5AUA12-059^({circumflex over ( )}) Positive Positive 90 6 WH12-287Positive Positive 75 7 WH12-307^({circumflex over ( )}) Benign Positive50 8 WH12-320 Positive Positive 40 9 AUA12-087 Positive Positive 100 10WH12-373 Benign Negative 0 11 WH12-390 Benign Negative 0 12 AUA12-088Positive Positive 80 13 AUA12-090 Benign Negative 1 14 WH12-401 BenignNegative 1 15 WH12-406 Atypical Positive 30 16 WH12-407 Benign Negative0 17 WH12-411 Benign Negative 0 18 RMH12-001 Benign Positive 10 19WH12-422 Positive Positive 95 20 RMH12-010 Atypical Positive 10 21WH12-424 Benign Positive 10 22 AUA12-101 Positive Positive 80 *An“atypical” Cytological assessment of cell morphology indicates thatcells in the sample have lost their normal appearance but have notreached the level of abnormality of malignant cells.^({circumflex over ( )})Sample re-stained

TABLE 4 Cytological assessment of cell morphology and telomeraseimmunostain results in clinically negative samples (biopsy proven).Immunostaining result Cytological assessment % Urothelial # Sienna ID ofcell morphology* Test result cells stained 1 AUA12-054 Benign Negative 12 WH12-268 Benign Positive 10 3 WH12-269 Benign Negative 2 4 WH12-274Benign Negative 0 5 WH12-276 Benign Negative 2 6 WH12-279 BenignNegative 0 7 WH12-282 Benign Negative 0 8 AUA12-058 Atypical Positive 209 WH12-283 Benign Positive 20 10 WH12-284 Benign Negative 1 11 WH12-285Benign Positive 10 12 WH12-286 Benign Negative 0 13 AUA12-060 BenignNegative 1 14 WH12-288 Benign Positive 10 15 WH12-290 Benign Negative 016 WH12-291 Atypical Positive 15 17 WH12-294 Positive Positive 50 18WH12-295 Benign Negative 0 19 WH12-297 Benign Negative 0 20 WH12-298Benign Negative 0 21 WH12-299 Benign Negative 5 22 WH12-301 BenignNegative 1.5 23 WH12-302 Benign Positive 10 24 WH12-304 Benign Negative1 25 WH12-305 Benign Negative 1 26 WH12-309 Benign Negative 2 27WH12-312 Benign Negative 2 28 WH12-313 Benign Positive 20 29 WH12-318Atypical Positive 10 30 WH12-319 Benign Negative 2 31 WH12-322 BenignNegative 1 32 WH12-324 Benign Negative 5 33 WH12-326 Benign Negative 034 WH12-327 Benign Negative 0 35 WH12-329 Benign Negative 1 36 WH12-330Benign Negative 1 37 WH12-331 Benign Negative 2 38 WH12-332 BenignNegative 1 39 WH12-336 Benign Negative 1 40 WH12-337 Benign Negative 141 WH12-339 Benign Negative 2 42 WH12-341 Benign Negative 2 43 WH12-342Benign Negative 2 44 AUA12-061 Benign Negative 5 45 AUA12-064 BenignNegative 2 46 AUA12-065 Benign Negative 5 47 AUA12-092 Benign Negative 148 WH12-368 Benign Negative 2 49 WH12-377 Benign Negative 1 50 WH12-378Benign Positive 10 51 WH12-387 Benign Negative 0 52 WH12-396 BenignNegative 0 53 AUA12-093 Benign Negative 5 54 AUA12-095 Benign Negative 155 WH12-400 Benign Negative 0 56 WH12-410 Benign Negative 0 57 WH12-412Benign Positive 10 58 RMH12-006 Benign Negative 2 59 RMH12-007 AtypicalNegative 5 60 RMH12-008 Benign Positive 20 61 AUA12-098 Benign Positive20 62 RMH12-009 Benign Positive 10 63 AUA12-099 Benign Negative 0 *An“atypical” cytological assessment of cell morphology indicates thatcells in the sample have lost their normal appearance but have notreached the level of abnormality of malignant cells.

TABLE 5 Clinical status, cytological assessment of cell morphology andtelomerase immunostain results in all samples (both clinically positiveand negative) that had an atypical cytology. Immunostaining resultCytological % Urothelial Follow up Clinical assessment of cell Testcells clinical # Sienna ID status morphology* result stained diagnosis 1 WH12-174{circumflex over ( )} Positive Atypical Positive 80  2WH12-178 Negative Atypical Negative  0  3 WH12-197 Negative AtypicalNegative  0  4 WH12-233 Negative Atypical Negative  0  5 WH12-234Negative Atypical Negative  0  6 AUA12-057 Positive Atypical Positive 10 7 AUA12-058 Negative Atypical Positive 20 Positive  8 WH12-289 PositiveAtypical Positive 75  9 WH12-291 Negative Atypical Positive 15 Positive10 WH12-318 Negative Atypical Positive 10 Cystectomy 11 WH12-353Negative Atypical Negative  0 12 WH12-361 Negative Atypical Negative  013 WH12-374 Negative Atypical Negative  1 14 WH12-406 Positive AtypicalPositive 30 15 RMH12-007 Negative Atypical Negative  5 16 RMH12-010Positive Atypical Positive 10 *An “atypical” cytological assessment ofcell morphology indicates that cells in the sample have lost theirnormal appearance but have not reached the level of abnormality ofmalignant cells. {circumflex over ( )}Sample re-stained

Example 3: Immunostaining of Telomerase in Bladder Cancer SamplesCorrelates with Disease

85 clinical samples were processed onto microscope slides and stainedusing the protocol described above. Minor adjustments to antibodyconditions or cell sample preparation were empirically determined on asample-to-sample basis. Every sample that received telomeraseimmunostaining also underwent standard cytological assessment of cellmorphology on the same sample. Cytological assessment of cell morphologywas scored as positive, negative, or atypical.

Cytological assessment of cell morphology and telomerase immunostainingresults were compared in clinically positive (Table 3) and clinicallynegative samples (Table 4). 22 clinically positive results were assessedwith 16 having telomerase positive staining. Of the 6 remainingclinically positive samples 6 were identified as benign followingcytological assessment of cell morphology. Accordingly, telomerase wasindicative of 16 out of 22 (72%) malignant bladder cancers.

63 clinically negative samples were assessed with 48 (76%) havingtelomerase negative staining. Of the 15 remaining clinically negativesamples, 11 (73%) were identified as benign following cytologicalassessment of cell morphology. The remaining 4 (27%) were identified asindeterminate (n=3) or positive (n=1) following cytological assessmentof cell morphology.

Telomerase staining correlating with disease is shown in FIG. 1. Nocellular staining was observed in sample WH11-107 (clinically negative;FIG. 1A). In contrast, significant cellular staining was observed in theclinically positive sample WH11-122 (FIG. 1B). In this sample, positivestaining, in the form of strong nuclear staining was observed in 40-75%of the urothelial cells present, under optimal antibody concentrations.It was interesting to note that, not all the urothelial cells present inthis clinical sample stained for the presence of telomerase hTERTprotein, suggesting that not all cells within the sample were cancerous.

Example 4: Resolving False-Negative and Indeterminate CytologicalAssessment of Cell Morphology

Every sample (n=85) that received telomerase immunostaining alsounderwent standard cytological assessment of cell morphology on the samesample. Cytological assessment of cell morphology was scored aspositive, negative, or atypical. All samples (both clinically positiveand negative) that were classified as atypical following cytologicalassessment of cell morphology (n=16) are shown in Table 5 together withthe associated scoring of the telomerase immunostaining.

The sixteen samples that had atypical cytology were evaluated using oneof two different immunostaining protocols, with and without a form ofepitope retrieval. There were eight samples in each protocol group, eachgiving similar results. Of the 16 samples, 5 samples were clinicallypositive and 11 were clinically negative. The telomerase immunostainingmethod assessed 5 of these 5 samples as positive (with >5% urothelialcells staining nuclear positive).

Of the 11 clinically negative samples, 8 were shown to be negative bythe immunostain test, and three were shown to be positive. Of thesethree, two patients in longitudinal follow-up were later assessed to beclinically positive (biopsy-proven; clinical samples AUA12-058;WH12-291). The other sample is currently pending confirmatory clinicalfollow-up (WH12-318). However, this patient underwent cystectomy.Performance of this procedure indicates that the patient was positivefor bladder cancer.

On the basis of current clinical status, the performance of thetelomerase immunostain test is 80% in specificity and 83% insensitivity, against cystoscopy. Furthermore, the immunostain resultprovided a correct diagnostic indicator (relative to cystoscopy) in atleast 94% of cases (15 of 16), (likely 100% of cases; 16 of 16 asWH12-318 underwent cystectomy) where cytological assessment of cellmorphology gave an inconclusive reading.

Example 5: Improving Diagnostic Readout

The unique method of preparing and immunostaining the clinical samplefor the presence of telomerase, and simultaneously cytologicallyassessing the binding of an anti-telomerase antibody to clinicallyrelevant cells and cytologically assessing cell morphology on a per-cellbasis allowed for significant diagnostic improvements over cytologicalassessment of cell morphology alone.

In FIG. 3, the power of resolving an indeterminate cytologicalassessment of cell morphology result, or salvaging a false-negativecytological assessment of cell morphology result, through telomeraseimmunostaining on a per-cell basis, is shown. In this figure, the cellsshown in all Panels are from a low grade bladder cancer clinical sampleoptimally immunostained for telomerase.

In Panel A, a non-bladder squamous cell is shown. This cell is not fromthe bladder and is visually excluded by trained cytologists from alldiagnostic determinations. It serves as a negative immunostainingcontrol in this clinical sample. As shown in panel A, the squamous cellis completely devoid of nuclear staining, as expected.

In Panel B, normal urothelial cells are shown. Both cells shown havewell defined shapes and nuclear: cytoplasmic ratios. To a trainedcytologist, these cells look completely normal, and would beappropriately defined as cytology negative following cytologicalassessment of cell morphology. The absence of nuclear immunostaining fortelomerase hTERT protein suggests that these urothelial cells, althoughthey were found in the voided urine of a patient known to have low gradebladder cancer, are very likely to be normal urothelial cells from anormal area of the bladder wall.

Panel C shows a morphologically normal urothelial cell of defined shapeand nuclear: cytoplasmic ratio, yet in this case, strong nuclearimmunostaining for telomerase hTERT protein is shown. This cytologicallynegative urothelial cell is, on the contrary, expressing abnormal levelsof nuclear telomerase and is thus extremely likely to be an early stagemalignant cell that has yet to show any morphological abnormalities.This conclusion is supported by the strong clinical correlation betweentelomerase hTERT immunostaining and clinical outcome shown in FIG. 2.

In the absence of telomerase immunostaining on the very same sample andthe very same cell on which a determination was made based on acytological assessment of cell morphology, this cell would have beendefined as normal or non-cancer by a trained cytologist and/orpathologist. This would be incorrect and result in a false-negative callon that specific cell. Accordingly, the per-cell immunostaining oftelomerase correctly determined this call.

In Panel D, a urothelial cell showing minor atypical traits, not strongenough to be called cytologically positive following cytologicalassessment of cell morphology by a trained cytologist, displays strongnuclear telomerase immunostaining. This is an example where individualcells classified as indeterminate after cytological assessment of cellmorphology can still be resolved successfully by telomerase hTERTimmunostaining under optimal conditions.

Example 6: Predicting Subsequent Development of Bladder Cancer

Three clinically negative samples, classified as inconclusive followingcytological assessment of cell morphology were shown to be positive bythe immunostain test. Of these three samples, two patients inlongitudinal follow-up were later assessed to be clinically positive(biopsy-proven; clinical samples AUA12-058; WH12-291). The other sampleis currently pending confirmatory clinical follow-up (WH12-318),however, this patient underwent cystectomy. Performance of thisprocedure indicates that the patient was positive for bladder cancer.

These data suggest that telomerase may be indicative of patients withincreased risk of developing bladder cancer. Accordingly, patientsclinically negative for cancer, which have provided samples that havepositive telomerase staining, may be placed under increased clinicalsurveillance.

Example 7: Telomerase Staining in Clinical Setting to Diagnose BladderCancer

A patient presents to a clinic with symptoms indicative of bladderdisease such as haematuria (blood in the urine), urinary frequencyurgency or burning sensation on urination. While, these symptoms can becaused by other, much less serious conditions than cancer, such as aurine infection, they are characteristic of bladder cancer.

Accordingly, a urine sample is obtained from the patient and sent forcytological assessment of cell morphology and telomerase immunostaining.If the results of the cytological assessment of cell morphology areinconclusive for bladder cancer, the clinician can use the telomeraseimmunostaining results to determine whether the patient has bladdercancer.

If the sample is telomerase positive, the improved sensitivity of thetelomerase assay over cytology at least warrants cystoscopicinvestigation for bladder cancer.

A cystoscopy can then be performed on the patient and if bladder canceris subsequently identified, the appropriate treatment regimen can beestablished.

Example 8: Telomerase Staining in Clinical Setting to Identify Risk ofDeveloping Bladder Cancer

A urine sample is obtained from a patient presenting with similarsymptoms to those discussed above. The sample is sent for cytologicalassessment of cell morphology and telomerase immunostaining. If theresults of the cytological assessment of cell morphology areinconclusive and the sample is telomerase positive, the clinician canrequest cystoscopic investigation for bladder cancer.

If bladder cancer is not subsequently identified in the patientfollowing cystoscopy, the evidence of the association between thebinding of an anti-telomerase antibody to clinically relevant cells andcancer development indicates that the patient likely has an increasedrisk of cancer. Accordingly, the appropriate surveillance regimen can beestablished.

Example 9: Comparative Immunostaining of Telomerase in Bladder CancerSamples

Telomerase staining was compared in clinical samples using the methodsoutlined above in Example 2. Comparative immunostaining was performedusing SCD-A7, Novus 2C4, Novus NB 100-297, Santa Cruz 377511, Santa Cruz7212, Rockland 600-401-252 and MBL M216-3 antibodies. Comparativeimmunostaining results are shown in Table 6.

Accordingly, various anti-telomerase antibodies can be used to resolveinconclusive cytological assessments.

TABLE 6 Cytological assessment of cell morphology and telomeraseimmunostaining results in clinically validated samples (biopsy proven)Anti-telomerase antibody test result Cytological Santa Santa RocklandSienna Clinical assessment of cell Sienna Novus Novus NB Cruz Cruz600-401- MBL ID status morphology* SC1-A7 2C4 100-297 SC-377511 SC-7212252 M216-3 AUA14- Negative Atypical Negative Negative Negative NegativeNegative Negative Negative 151 AUA14- Positive Atypical Positive # # # ## Positive 160 AUA14- Positive Atypical Positive Positive PositivePositive Positive Positive Positive 168 AUA14- Positive AtypicalPositive # # Positive Positive # # 173 AUA14- Positive Atypical PositivePositive Positive Positive Positive Positive Negative 187 RMH13-Positive Atypical Positive # Positive # # # # 058 RMH13- PositiveAtypical Positive Positive # # # Positive # 069 Correctly resolvedinconclusive 7/7 4/4 4/4 4/4 4/4 4/4 3/4 cytological assessment % %-2samples excluded from analysis as clinical status could not bedetermined; AUA14-158; AUA14-172. #-Insufficient material available tostain. *An “atypical” cytological assessment of cell morphologyindicates that cells in the sample have lost their normal appearance buthave not reached the level of abnormality of malignant cells.

Example 10—Slide Reading Algorithm

Two slide reading algorithms have been evaluated utilising the clinicalsamples described in Example 1. The first algorithm involves counting ofboth urothelial and squamous cells with positive nuclear staining fortelomerase. A positive test result is determined based on the percentageof cells stained. The second algorithm involves assessing morphologicalchanges in urothelial cells in combination with positive nuclearstaining for telomerase to derive a positive test result.

Reading Algorithm—5% Cut Off

Slides were assessed at a magnification of ×200-400 and visually scannedacross an adequate number of fields of view to identify more than 20urothelial cells. The following cell numbers were recorded:

-   -   1. The number of urothelial cells showing nuclear staining.    -   2. The number of urothelial cells identified/evaluated in the        process of recording point (1) above.

The following particulars were also noted:

-   -   1. Urothelial staining characteristics (nuclear/cytoplasmic).    -   2. Percentage of squamous cells showing nuclear staining        (including both cells with or without cytoplasmic staining).    -   3. Total number of squamous epithelial cells evaluated.

For this algorithm, a positive test result was defined as a slide inwhich more than 5% of the urothelial cells demonstrated positive nuclearstaining (i.e. more than about 2 to 3 cells with positive nuclearstaining per 20 urothelial cells).

Reading Algorithm—Morphology Based

Slides were assessed to identify urothelial cells demonstratingmorphological atypia (e.g. high nuclear to cytoplasmic ratio, nuclearchromatin variation, irregular nuclear outlines). Cells demonstratingmorphological atypia were then assessed for the presence or absence of apositive immunocytochemistry signal.

Corresponding Papanicolau stained urine preparations were examined inconjunction with the telomerase immunocytochemistry slide duringevaluation of clinical samples.

For this algorithm, a positive test result was defined as a slide inwhich the urothelial cells demonstrated morphological atypia in thepresence of a positive nuclear stain.

Comparison of Reading Algorithms

Comparison of the above reading algorithms is summarised in Table 7.Review of slides using morphology in combination with telomerasepositive staining of cells resulted in an overall sensitivity of 83.3%whereas the 5% Cut off Algorithm resulted in an overall sensitivity of57.1%. The sensitivity for the detection of Low Grade urothelialcarcinoma increased to 75.0% using the morphology based readingalgorithm in comparison to 50.0% achieved with the 5% cut off algorithm.

The morphology based algorithm demonstrates increased sensitivity andspecificity for the overall detection of urothelial carcinoma as well asincreased sensitivity and specificity for both high and low gradedisease classifications in comparison to the 5% cut off algorithm.

Nonetheless, the 5% cutoff algorithm also provided an effective approachfor resolving an inconclusive cytological assessment in the analysedbladder cancer samples. For example, it is anticipated that 1 cell withpositive nuclear staining per 20 urothelial cells indicates a positivetest result.

TABLE 7 Comparison of the 5% Cut off and Morphology Based Algorithmresults. 5% Cut Off Algorithm Morphology Based Algorithm High Grade LowGrade High Grade Low Grade Test Statistics Overall Disease DiseaseOverall Disease Disease Number 31 20 27 27 18 23 Sensitivity 57.1%100.0% 50.0% 83.3% 100.0% 75.0% Specificity 58.8%  58.8% 58.8% 86.7% 86.7% 86.7% Likelihood Ratio for 1.39 2.43 1.21 6.25 7.50 5.63 PositiveTest (LR+) Likelihood Ratio for 0.73 0.00 0.85 0.19 0.00 0.29 NegativeTest (LR−) Positive Predictive 53.3%  30.0% 41.7% 83.3%  60.0% 75.0%Value (PPV) Negative Predictive 62.5% 100.0% 66.7% 86.7% 100.0% 86.7%Value (NPV) Diagnostic Accuracy 58.1%  65.0% 55.6% 85.2%  88.9% 82.6%

It will be appreciated by persons skilled in the art that numerousvariations and/or modifications may be made to the disclosure as shownin the specific embodiments without departing from the spirit or scopeof the disclosure as broadly described. The present embodiments are,therefore, to be considered in all respects as illustrative and notrestrictive.

The present application claims priority from AU 2014900494 filed 17 Feb.2014, the disclosures of which are incorporated herein by reference.

All publications discussed and/or referenced herein are incorporatedherein in their entirety.

Any discussion of documents, acts, materials, devices, articles or thelike which has been included in the present specification is solely forthe purpose of providing a context for the present disclosure. It is notto be taken as an admission that any or all of these matters form partof the prior art base or were common general knowledge in the fieldrelevant to the present disclosure as it existed before the prioritydate of each claim of this application.

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The invention claimed is:
 1. A method for detecting bladder cancerepithelial cells comprising: performing a cytological assessment ofcells in a fluid sample comprising bladder epithelial cells, whereinsaid performing detects bladder epithelial cells having atypical cellmorphology that is indeterminate of malignancy, wherein the sample isfrom a subject suspected of having bladder cancer; contacting the samplewith an anti-telomerase antibody; and detecting binding of theanti-telomerase antibody to the bladder epithelial cells having atypicalcell morphology that is indeterminate of malignancy.
 2. The method ofclaim 1, wherein the performing cytological assessment and the detectingbinding of the anti-telomerase antibody to the bladder epithelial cellsare performed simultaneously on the same cells.
 3. The method of claim1, wherein the sample is selected from the group consisting of urine,bladder washings, bladder scrubbings.
 4. The method of claim 1, whereinthe sample is urine.
 5. The method of claim 1, wherein said detectingbinding of the anti-telomerase antibody is by an automated immunoassay.6. The method of claim 1, wherein said detecting binding of theanti-telomerase antibody is by cytological assessment.
 7. The method ofclaim 1, wherein the anti-telomerase antibody is monoclonal, bispecific,chimeric, recombinant, humanized, single-chain antibody molecule, orantigen-binding fragment of an anti-telomerase antibody.
 8. The methodof claim 1, wherein the anti-telomerase antibody is s polyclonalantibody.